The Health Action Model (HAM) provides an inclusive framework of key predictors (belief, motivation, and normative systems) of choice and intention of healthy behaviour that can be applied to breast cancer screening among women from the MENA region. However, facilitating factors are needed for action to occur. The HAM suggests you cannot separate the design of targeted effective health promotion programs from the historic and cultural contexts of the participants for whom they are intended.13 This inclusiveness of the HAM results in understanding key sociocultural and ecological determinants of health-related actions beyond the level of individual health.13

Participants in this study were generally lacking a holistic approach to health. They articulated that the absence of physical illness means to them that they are healthy and free of serious disease.

Multiple factors play a role in this limited understanding of health. Gender disparities are embodied in social norms, and single women who pursue sexual or reproductive health services are met with shame and stigma.7,14 Islam forbids any sexual activities or conceiving of children outside of marriage, and in Middle Eastern cultures, for example, breasts are mainly seen as symbols of sex and breastfeeding; hence single women are not expected to adopt breast health measures in traditional Arab Muslim society.

Poor knowledge of screening practices was a common finding in this study. Mammography is still unknown to most participants. The few participants who recognized mammograms as a breast cancer screening tool had a debate on mammography risks given that it has advantages and disadvantages. Therefore, women are encouraged to learn about breast health and screening strategies to make informed decisions.

Language barriers. Similar to findings from previous cross-cultural research, language difficulties were reported as a main challenge in accessing health care.5,7,14,15 Failure to remove these barriers hinders an individual’s ability to transform their intentions into actions.13,16 Bilingual services and events could increase knowledge of Canadian culture, connect newcomers to settlement services to help bridge gaps, and assist with adjustment.5,7,8 While relevant literature describes the role of the individual as vital to health literacy, others argue about the significant impact health care providers can have on the health literacy of service seekers.6,8 Institutional elements including health care services, programs, and providers were recognized as affecting newcomers’ health decisions and actions.6,7,17

Education, empowerment, and implications for health literacy. In this study, female participants were highly motivated to improve their health. Receiving education and direction on breast cancer screening practices were common goals. Participants indicated that their empowerment would enable them to go beyond fear and take control over their breast health. One participant stated: “The more I know, the less fear [I have] inside me.” Scholars have pointed out that having a high education level does not necessarily guarantee an individual access to health care and better health outcomes.18

The concept of critical health literacy, which involves the ability to engage with knowledge critically and to take action to improve health, has received wide interest.19 Critical health literacy can be obtained by both the educator and the learner working in a collaborative environment and benefiting from each other’s skills and resources.6,19 Context is a key factor that shapes how women from MENA countries perceive and practise breast health. Bridging the voices of women from MENA countries with those of decision makers could result in greater uptake of breast cancer screening services.15,20

Health care providers. The sex of health care providers was a critical factor in these participants’ willingness to take part in breast cancer screening. Most participants in this study stressed the need to respect their modesty in a clinical care setting and to offer a female health care provider. Institutional issues related to the modesty and privacy needs of Muslim women have been found to be sources of distress and reasons for not using health care services.5,14

Participants in this study also revealed negative experiences in health care settings that had discouraged them from using the services. This emphasizes the need to eradicate discrimination and stereotyping in health care settings and to provide cultural competency training. Disrespecting alternative medicine or asking young single Arab Muslim women about sexuality, for example, would be considered offensive and may cause extreme embarrassment for families from MENA countries.14 However, this is a good example of a topic on which health care providers could be trained to help them offer culturally appropriate health care to Arab Muslim populations.

Social influences and Islamic values. Important factors that hinder an individual’s decision to seek health care services are their perceptions of the health condition and expected social reactions to it.13 Social pressures on individuals can result in feelings of shame and stigma.13 The fact that the breast is attached to reproductive and sexual functions may create social stigma surrounding breast cancer in MENA communities.21 Fear of disgrace and social stigma could also be reasons for worries about adverse screening outcomes. In Arab cultures diseases such as cancer are viewed as shameful and something that should be hidden.14

Findings of this study show that cultural beliefs strongly influence the views of women originally from MENA countries toward screening and preventive health care. Culturally aware messaging could be carefully integrated into health education programs and services targeting these women to motivate their participation in breast cancer screening.8,15

Study participants identified multiple cultural concepts that mesh with their Arab identities and their Islamic perceptions of health. Their perspectives on cultural issues should be integrated into services intended for them. Taking a HAM-based perspective, these customized interventions would generate a strong positive interaction of belief and motivation systems that then translate intentions into practice.13

Breast cancer is a leading cause of cancer deaths among women in Canada and globally,1 and in a culturally diverse country such as Canada it is important to understand the viewpoints of women from immigrant populations. Researchers may use data from this study to conduct collaborative and participatory action research to apply interventions to drive change. Findings of this study could help Canadian primary care providers improve how they communicate with patients from MENA communities and understand their patients’ wider social determinants of health. Potential solutions for overcoming screening barriers proposed in this article could be used to tailor appropriate health education for women originally from MENA countries and to encourage them to use screening services.